![]() The cause map’s level of complexity, however, is dictated by how useful each problem element is to determining solutions. The more closely we examine the Columbia disaster, the more elements we can identify that cumulated in a tragic loss of life. While the loss of all seven Columbia crew members upon re-entry may seem like the obvious problem, root cause analysis requires probing deeper to arrive at complex chain of causality with multiple problem sources. The first step in any root cause analysis approach is to define the problem by asking four critical questions: What is the problem? As with any incident, root cause analysis involves three steps:Įach step will be discussed below in relation to the Columbia disaster. The disintegration and loss of the space shuttle Columbia on re-entry serves as an example of how root cause analysis can be applied to a specific incident. In investigating the incident methodologically, root cause analysis illuminates not only what indications of danger were missed, but also why they were overlooked, while proposing solutions to ensure that the same mistakes are never re-made. The Columbia disaster thus came as a terrible surprise to those involved, and carried dramatic consequences for NASA’s future missions. Even the errant piece of foam that struck Columbia’s wing during launch had been detected and was deemed not to have been a safety concern well before reentry was attempted. Given its successful prior 27 missions, Columbia benefitted from an experienced command crew at the control center, and from a space vehicle that had been tested and appeared reliable. The Columbia disaster serves as a prime example of the value of root cause analysis precisely because every aspect of the mission had seemed so routine. By Columbia’s twenty eighth launch, engineers had come to see such foam debris as inevitable, presenting at worst an acceptable risk.Īfter spending 16 days in space, Columbia broke apart when reentering Earth’s atmosphere on February 1, 2003, resulting in the total destruction of the orbiter and killing all seven astronauts aboard. Such occurrences were given the name of “foam shedding,” normalizing the process even further. During launch, a briefcase-sized piece of foam insulation broke off from the shuttle’s external tank and struck the left wing, damaging its thermal protection system, which protects the vehicle from the intense heat generated upon reentry.Īlthough such foam shedding was technically listed as a safety issue in the original shuttle design specifications, the same kind of foam insulation had been observed falling off on four previous flights and had caused no serious damage. This notion came to a sudden end during the shuttle’s 28th mission (STS-107). Colombia’s long running success, especially in the wake of the 1986 Challenger explosion signaled to some that human space travel was approaching the point at which it might be considered routine. The first space-worthy space shuttle in NASA’s orbital fleet, Columbia was first launched in April of 1981, and had successfully completed 27 missions by 2003. The Columbia space shuttle was a seasoned veteran of space travel.
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